Provider Demographics
NPI:1033853114
Name:DOUGHERTY, HEATHER TIFFANY (MSN RN PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:TIFFANY
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:MSN RN PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-3034
Mailing Address - Country:US
Mailing Address - Phone:760-703-7380
Mailing Address - Fax:
Practice Address - Street 1:11770 BERNARDO PLAZA CT STE 370
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2426
Practice Address - Country:US
Practice Address - Phone:858-673-3360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95093407163WP0808X
CA95021374363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health